The Sticky Subject of Patient Responsibility

Over the last couple of days I've heard this suggestion on the radio:  reimbursements for physicians should be restructured such that they are based on patient outcomes.

I disagree.

For almost any other profession or trade, payment is based on a certain expectation of skill and work.  I don't wait till after a job is done to pay my carpenter or plumber; he or she charges a rate based on the "going" rate for the job at that particular level of training, and a job well done is expected.  If a job is not well done, some money wrangling can ensue; but a priori the quoted rate is based on things other than outcome.

But that's not why I disagree.  I disagree because a reimbursement system based on patient outcome makes the assumption that physicians are entirely in control of outcome, when the fact of the matter is some patients bring factors to a given situation that portend poor outcomes.  Some of these factors - genetics, environmental exposure - are largely out of patients' control; others, however, derive directly from patients' habits and choices.  

Reimbursement based on outcome completely absolves patients from any kind of responsibility for their own health.  Physicians whose patients, for example, insist on smoking liking smoke stacks all day every day for decades would be punished merely for having such patients on their rosters.  Reimbursement based on outcome would also punish those physicians whose patient populations live at increased risk for disorders such as asthma or malnutrition by virtue of their geographic or socioeconomic lot in life and would reward physicians who live in Gucciville, USA and practice at Dolce & Gabbana Hospital, simply because their more advantaged patients happen to be healthier.  

One report I heard held up transplants, and the rigorous outcome measures applied for patients receiving them, as an example of why such a system would ultimately compel physicians to do better.  I believe this is a disingenuous comparison; transplants are highly specialized clinical scenarios on which physician practices have direct, observable, concrete impact, but many of the situations that arise in primary care medicine depend as much on patients' actions as on those of physicians.  

I firmly believe physicians should be responsible for the care they provide.  I believe they should accept responsbility for shortfalls in care and always strive to improve.  But I also believe patients, who so often voice the desire to be decision-making partners with their physicians, should also take some responsibility for their own health.  If my primary care physician is going to have some dollars taken from her because my blood pressure is still high on my next visit, some dollars should be required of me to compensate her for the loss because despite her entreaties I have not been consistent about getting enough exercise, maintaining a healthy weight, eating a healthy diet, or what-have-you.

Physicians aren't all-powerful.  They shouldn't be expected to work miracles, change genetics, manipulate temperament, cure addiction, or read people's minds when they are lying or failing to disclose all pertinent facts.  We as patients need to do the work of taking care of ourselves, reporting our symptoms and habits truthfully, making efforts to improve our lives. Only then can the doctor-patient relationship be a kind of "partnering" interaction.

[Photo: painting by Jules Adler of a blood transfusion from goat to human, hanging above a huge staircase at the Université René Descartes.]

What Stinks?

Here's another memory for the "only in Paris" category.

We had just gotten through security at the airport.  We were walking toward our gate, past the usual array of shops selling luggage, designer scarves, and chocolate.  All of a sudden an unmistakeable odor assailed us.

"What is that SMELL?! Did someone...?" 

Not long after waiting ten minutes for the saleswoman at the Maison du Chocolat counter to place four tiny chocolates into a bag, between conversations with her fellow saleswoman that inexplicably could not wait until after she had finished bagging our minuscule order, we found the source of the pungent odor.

The duty free shop across the way.  It had a CHEESE section.  As if passing all the major historic sites of Paris on the drive out of the city hadn't been enough salt in our wounds, here was an olfactory reminder from Paris, which seemed to be telling us with her characteristic self-satisfaction, "Yes, here, only here, can you find the world's finest culinary delights, and you are leaving them all behind. I stink wonderfully in your general direction.  Enjoy and weep."  

On top of that, in a final, almost iconic gesture of inexplicable, arbitrary Parisian unpleasantness, the saleswoman in THAT shop curtly hissed at me, when I tried to snatch a bloggable memento of this cheese corner, "Taking photos is forbidden!" I mean, honestly.  Why the heck should you care, lady?  Leave me alone. I took one anyway, because I can  be stubborn and defiant, but I couldn't get a really good one.

But it was soooooo typical.  Paris shopkeepers will make up a rule on the spot if you so much as get a hair out of place that annoys them.  They'll size you up to see if you're worthy of their attention.  They will look down on you if you're too sweet. They will take FOR. EVER. to do the smallest thing - wrap an item in tissue paper, top a pizza, enter information into a log book - often because they'll be chit-chatting at the same time (after all, how dare you intrude on their day by actually wanting service).  If you get a defective product, forget about returns, exchanges, or refunds that you've tried to obtain after standing forty to sixty minutes in a line that several Parisians have tried to jump.  Besides, who are you to assert their products are defective?  How dare you.  Lowly expat.

Customer service and work ethic seem totally absent in the workings of small French businesses.  As a Frenchman once said to me of his perception of the French mentality toward work, "Employment is just a vehicle for obtaining paid vacation and paid maternity leave. Why should they put in more than minimum effort when they can get a lot of benefits and by law can almost never get fired?"  I realized that the motivation, the drive, to work as hard as possible, as efficiently as possible, and always try to do better than one has done before, is very, very American.  "Your French employees would never tolerate your standards if you tried to run a business here American-style," he continued, as if reading my thoughts.

I found myself pondering these annoyances as I sat in the airport trying not to be sad about leaving.  Trying to convince myself that visiting was great, but living here would be a pain.  Would I really want to spend the rest of my days in a place where people don't seem to believe in deodorant, or shower curtains, or proper food preparation hygiene, or air conditioning during heat waves? Where they just have to judge you by appearances, and everything has to be just so? Where the bureaucrats are arbitrary and nasty, and the red tape thicker than the Conciergerie walls?  Where a single load of laundry (about half the volume of a load in the States) takes two hours to get through a wash cycle, where nothing's open late or on weekends, where you're lucky if you can find a bathroom in a public place, much less a clean one, and where it seems people would almost rather let someone exsanguinate in front of them rather than take the initiative - rather than be bothered - to help a person who's hurt?

The truth is, I could totally see myself living there, despite all my pet peeves.  I could make a pet peeve list for any country - the Philippines, the United States - just as I could make a list of things that make those places great.  Every time I go to France to visit my husband's family, I fall in love with it all over again, and every time I have to leave France, my heart aches a little more.  I don't know that I could ever develop a true sense of belonging over there, but that has eluded me almost everywhere, so that wouldn't be such a big deal.  

I wonder what makes our souls crave certain places with an almost primal longing.  I guess I'm not going to solve that mystery any time soon.  One thing's certain:  I definitely appreciated the more laid-back demeanor of the folks we've encountered back on American soil.  People live and let live over here, and it was nice to come home to that.

Au Revoir

Passage d'Enfer - mais pas vraiment

I had a chance to take a leisurely stroll through Paris on my own today - our last full day here - mostly in the St. Sulpice and Odéon area.  It was nice to find some tucked-away corners, be asked for directions as if I were a local, have no major tourist-y goals, and just enjoy wandering through a city I've really come to love.

It's midnight here.  The Eiffel Tower is in the middle of its hourly sparkle.  It's probably the last time we'll be seeing it for a long while.

My heart hurts.

What We Did in London

Fifteen years ago I came to London and fell head-over-heels in love with it.  Today, thanks to my family situation, I think I  might actually have more affection for Paris despite my past love-hate relationship with the city, but London still has a very special place in my heart.

We only had a couple of days here visiting some of my cousins, but we did do many typical touristy things:  took pictures in front of Big Ben; visited Trafalgar Square, Shakespeare's Globe (where we got to watch part of a rehearsal of Troilus and Cressida), and the Tower of London; ate fish and chips; and watched street performers in the lively environs of Covent Garden's Central Market.  My daughter went with her cousin to see a West End show (Sister Act), of course.  

I made some food discoveries:  the soup-and-sandwich chain EAT, where one can get delicious food made with fresh ingredients (I had edamame salad with Thai dressing, delectable pho, and a light sandwich); the cupcakes at the London Review of Books Cake Shop at Bury Place off Bloomsbury Way, thanks to a tip from Shuna; and the  De Gustibus, where I found some absolutely heavenly blueberry cakes and chocolate-dipped brownie sticks.  

We also did some quieter, less flashy things that made this trip even more enjoyable:

My daughter and I enjoyed the brass rubbing center at St. Martin-in-the-Fields, between the gift shop and the crypt café.  Great way to relax on a rainy day.

My whole family enjoyed Cecil's Court, a quiet pedestrian lane just off Charing Cross Road that has some wonderful book shops for those who love browsing.

And finally, the highlight of this visit to London, for me, was All-Hallows-by-the-Tower, a church across the way from the Tower of London and the oldest church in the city (originally founded in 675).  Here the bodies of Bishop John Fisher and Thomas More were sent for a time after their executions; John Adams was married and William Penn was baptized; Samuel Pepys watched the Great Fire of London; and an old Saxon arch was uncovered during a bomb blast.  Here you can find a mariner's chapel, with models of ships hanging from the arches; a brass-rubbing center; and many interesting pieces of art, old and new, including an embroidered banner dedicated to prisoners of conscience.  I came here alone after a long day of sightseeing to recharge at a Taizé prayer service, and it was like drinking cool water after a day of thirst.

Some of the best moments of any trip are those spent finding and enjoying some "hidden treasures."  We've certainly found our share here.

Walking Among 5000-Year-Old Secrets

I hope blogs are considered "personal use" of photographs; those were the rules about Stonehenge pictures.  I cannot believe we were standing right in the middle of the stone circle today.  I don't have word to describe how amazing it was, but I have pictures.  

Stonehenge at dusk:

A portal to an ancient, lost world...

Rain clouds gathering; my husband and son tiny next to the sarsens...

One last look...

My Beef with the American Educational System

After hearing French people talk about their schooling, I am of two minds.  

I think American students should be required to pass a national exam like the bac (or the British A levels) at the end of high school.  We're not held accountable for our learning at ALL in the states.  We should be able to do more than recognize an answer among multiple choices; we should be able to write about our ideas and discuss our knowledge base, such as it is, in conversation.  It's no wonder that French students who pass the bac qualify to start as sophomores in American universities.  They're just held to a higher standard, one I think we should try to emulate.

The problem with the bac as it is right now, according to the French, is that it's a bit of an elitist exam. It's not that every exam that requires some actual critical thinking and expression must, forcément, be elitist.  But the content makes it so, apparently - so perhaps it's time to revise the traditional exam.  I don't know.  

I do know, from my husband's first-hand experience as well from conversations with our French relatives, that the French system can be extremely rigid, inimical to creativity, and inflexible, in that young people are shafted into a particular track early, with little opportunity for transfer should that be their desire later - either because their aptitude in a particular area improves, or because they're miserable in the original track and want to do something else.  I have the American system to thank for being pliant enough to allow an English major to attend medical school; such a path would be next to impossible in France, from what I understand.

I'm still mulling this over.  Neither system is perfect, but it's clear to me that young Americans are in some ways far behind their European counterparts in terms of responsibility for their learning.